AMSA's 2015 Annual Convention
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February 26 - March 1, 2015 

Using Your Heart

The New Physician April 2001
Finding the right emotional balance between you and your patients is not only essential to practicing good medicine but
also important to your health.



It is the great paradox of practicing medicine: In order to be a good physician, you must be empathetic and caring, but in order to preserve your sanity, you must maintain an appropriate emotional distance from patients. You can’t get too involved, and you can’t be too detached. Finding and maintaining this delicate balance may well be one of the most important skills in the successful practice of medicine, equally as valuable as knowing how to take a medical history or recognizing the signs of sepsis. Yet it is something that is rarely, if ever, mentioned in medical school. In fact, the culture of medicine seems at pains to tell young physicians not to talk about their feelings.


“In training doctors, we tend to train the head and train the hands but leave out the heart,” says Dr. Sandra Frazier, an assistant professor of psychiatry at the University of Alabama at Birmingham (UAB).


Dr. Brad Stuart, the medical director of the hospice program at Sutter Health in California, agrees. “In medical training, you get a lot of points for being strong and putting your own needs aside. Keeping a certain emotional distance is rewarded.” This may be understandable in a profession in which dealing with pain and suffering is common, almost routine, but many physicians say this is not necessarily the best strategy. Distant, overly detached physicians rarely give their patients what they need or want. And repressing emotions is certainly not good for the physician.


CRYING THE IN THE STAIRWELL


As the director of UAB’s “Health for the Healer” program and a practicing psychiatrist, Frazier spends much of her time helping physicians cope with their emotional difficulties. Most of the physicians who attend the healer workshops either have problems interacting with staff or with patients. If the difficulty involves dealing with the loss of a patient, Frazier says she can relate to the physician’s feelings. When she was a young resident, she suffered the loss of a baby under her care. Overwhelmed with emotion, she retreated to the privacy of a stairwell and sobbed. The emotional release helped, but she says it would have been better if physicians had a less furtive means of dealing with emotions.


Crying, in the stairwell or elsewhere, is common, though rarely admitted, among physicians-in-training. For the past several years, Dr. Nancy Angoff, the assistant dean of student affairs at Yale University School of Medicine, has been asking medical students if they ever cried during clinical rotations. And of the 182 students she informally surveyed, 133 admitted to having cried at least once during their clinical training. Occasionally the tears were a response to stress or frustration, but far more often they arose from a deep empathy with and compassion for patients. In the Journal of the American Medical Association article that details her research, Angoff says students often worry that, in the course of their training and in practicing medicine, they will lose the capacity to feel compassion for patients. And she says other students fear that displays of emotion indicate they’re “not tough enough” to practice in this field. Many physicians say mentors can show students how to find that emotional balance. The only difficulty, they say, is finding a mentor who is good at it.


Dr. Michael Rabow, an assistant clinical professor of medicine at the University of California, San Francisco, says he has developed a specific way of coping with the death of a patient. “I spend time at the bedside of patients who have died in order to say goodbye. I also share my feelings about them with their families as well as with other clinicians. And I have a small, personal ritual that I perform after a patient has died: I fold an origami crane to serve as a visible reminder of the person I have cared for.”


Some physicians, however, don’t appear to have any emotions at all. In practice, this leads to what Stuart calls “the hand on the doorknob” syndrome—a physician listening to a patient while preparing to escape at the first opportunity. The physician may act as if he’s with the patient, but emotionally, he’s somewhere else. Obviously this is not good for the patient, but what may not be so clear is that physicians who do this are damaging themselves as well.


“In medical training,” Frazier says, “physicians learn not to show weakness; they learn how to distance themselves. Eventually that’s the only way they know how to respond.” This spills over into the physician’s private life and can create all sorts of problems, from difficulties maintaining relationships to depression and substance abuse.


Physicians can’t blame all their emotional problems on their training, though. “The training certainly may exacerbate problems, but it doesn’t create them,” she says. “Like the rest of society, physicians have a lot of baggage; many physicians come from dysfunctional families and carry deep wounds. The culture of medicine, however, makes it easy for doctors to stay busy and avoid addressing these issues. By their very nature, doctors tend to be the type of people who intellectualize their problems.” This makes it easy for physicians to neglect their emotional needs. When they do, “they often project their own needs onto their patients,” she says. “This can result in either getting too involved or staying too remote from patients.”


It is only natural that a patient’s suffering could evoke a similar response in the physician. Stuart calls this “resonance.” He says it can be useful but often causes problems, especially when it “evokes the doctor’s own unacknowledged suffering.” The best way to handle resonance is to pay very close attention to your emotions. Both Stuart and Frazier say that when a physician really dislikes a patient or finds himself particularly uncomfortable with one, it’s a sign he needs to examine any personal issues he may have that are being touched by the patient. “The practice of medicine is a path to self-awareness,” Stuart says.


Some physicians have been fortunate in their training. Dr. Amy Pedone, a family practice intern at York Hospital in York, Pennsylvania, says her early medical school years helped ease the transition from the classroom to the bedside. “I actually started seeing patients during my first year of medical school at the University of Virginia,” she says. “We had a course called DPI [the doctor, the patient, the illness]. In this class, we took turns gathering histories from patients and then would have small group discussions about how those encounters went and what our feelings were. Because of this experience, I found it relatively easy to make the transition to seeing patients on a more frequent basis as a third-year medical student.”


TIPS FOR FINDING BALANCE


Though it is not easy, some physicians manage, almost instinctively, to find balance between too much and too little emotional involvement. “Most truly compassionate physicians,” Stuart says, “get close to their patients within moments.” He says for these physicians, this can be done quickly because it is “not a matter of time but of presence. Excellent physicians are extremely ‘there’ with their patients, yet they still maintain their own center.”


If this sounds a little like Zen, that may be because there is a spiritual aspect to it. “It is spiritual,” he says, “in the sense that [once you learn how to do this], self-knowledge and wisdom come out of it.”


Like most disciplines—whether they’re spiritual or mental—with sufficient effort this one can be learned. Frazier offers some practical tips for maintaining balance. First, she urges all physicians to have a primary care physician. “Don’t try to self-diagnose or self-prescribe,” she cautions. “You can get into a lot of trouble trying to be your own doctor.”


Second, she recommends physicians consider seeking counsel during challenging times. “This can be an enormous help in such a stressful profession. Don’t get caught in the trap of trying to deal with everything yourself.”


Lastly, she suggests physicians take plenty of time off. “The medical profession rewards workaholics, but this is not good. You have to get away to get clarity on issues. Learn to nurture yourself with simple things.”


In a profession where the demands are so great, avoiding burnout takes a conscious effort. “Choose at least one thing to do that is as important to you as everything else in your life—something you refuse to compromise on,” Rabow says. “Whatever you choose—whether [it’s] meditation, psychotherapy, exercise, learning to dance, or making regular calls to family—make it a part of your ‘practice’ in the same way you ‘practice’ medicine. And, of course, have compassion for yourself.”


And if you can find a supportive working environment, that can help as well, Pedone says. “I recall a particularly challenging day when I was post-call on a new rotation and feeling very overwhelmed,” she says. “My colleagues picked up on my frustration pretty quickly and offered to help. I’m very fortunate to be in an extremely supportive environment. I feel as though I could go to any of my fellow residents and attendings with any issues that might arise.”


All physicians—new and experienced—face challenges when trying to manage this emotional balancing act. But new physicians have a unique opportunity: You can work toward getting it right at the outset of your career; you can develop a good emotional practice from the beginning.


“In medical training, we’re taught to disregard our feelings because they get in the way,” Stuart says. “Especially troublesome, we are told, are strong feelings like sadness and joy. But once you are in practice, you learn that knowing your own feelings is critical. Suffering patients—folks who just got a cancer diagnosis, people who are about to lose someone they love—all these people are either dealing with grief or hiding it. Being sensitive to your own grief lets you feel it in others, so you can help them become aware of it and work through it. But being able to help others through this process means being familiar with it in yourself.”


Medical students who worry about showing emotion shouldn’t fret. “What you now perceive to be your greatest vulnerabilities may turn out to be your greatest strengths.” Don’t worry about how you’ll know when you’ve got it right, he says. “Your patients will let you know.”
Avery Hurt is a freelance writer based in Birmingham, Alabama.